ATI CBC LEVEL 3 MEDICAL SURGICAL
NURSING CORE TOPICS REVIEW SHEET
FULL ANSWER COLLECTION
●● A nurse is caring for an older adult client. The client received 0.9%
sodium chloride 1 L over 4 hr instead of over 8 hr as prescribed. Which
of the following entries is the appropriate documentation of this
occurrence in the client's medical record?
Answer: 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs
stable.- The nurse should document the amount of fluid, how long it
took to infuse, and the client's physical status.
●● When planning care for a child who has increased intracranial
pressure (ICP), which of the following should the nurse include in the
child's plan of care?
Answer: Maintain head in midline. -The child's head should be
maintained in a midline position to promote venous return and prevent
an increase in ICP.
●●
Answer: Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty
arousing the client from sleep is an indication of increased ICP.//
,Widening pulse pressure is correct. A widening pulse pressure (increase
in systolic with concurrent decrease in diastolic blood pressure) is an
indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate
posturing indicate increased ICP.
●● A nurse is talking with a client who is beginning chemotherapy. She
tells the nurse that she is mourning the loss of her hair. Which of the
following actions should the nurse take first?
Answer: Discuss the importance of hair with the client.--The first action
the nurse should take using the nursing process is to assess the client. By
identifying the importance of hair to the client, the nurse can
acknowledge the importance of the expected loss to the client and assist
the client with anticipatory grieving.
●●
Answer: an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require
planning and math skills, such as managing finances.
●●
Answer: Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic
cerebral palsy.
, ●●
Answer: Discontinue the infusion.--A report of pain and a red line
extending outward from the insertion site are manifestations of phlebitis
and indicates that the client is at the greatest risk from injury to the vein;
therefore, the first action the nurse should take is to discontinue the
infusion.
●● A client who is being discharged today asks the nurse for supplies for
her wound dressing. Which of the following actions should the nurse
take to ensure quality, cost-effective care?
Answer: Provide enough supplies for 1 to 2 days.-Although wound care
supplies for home use are typically purchased by clients after leaving the
facility, it may be necessary to provide adequate supplies for the
immediate discharge period.
●● A nurse is administering baclofen for a client who has a spinal cord
injury. Which of the following should the nurse document as a
therapeutic outcome?
Answer: Decrease in flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms,
allowing for improved muscle function.
●● A nurse is providing postoperative instructions about complete
proteins to a client following a below-the-knee amputation. Which of the
following food choices indicates a need for additional instruction?
Answer: Pinto beans-
NURSING CORE TOPICS REVIEW SHEET
FULL ANSWER COLLECTION
●● A nurse is caring for an older adult client. The client received 0.9%
sodium chloride 1 L over 4 hr instead of over 8 hr as prescribed. Which
of the following entries is the appropriate documentation of this
occurrence in the client's medical record?
Answer: 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs
stable.- The nurse should document the amount of fluid, how long it
took to infuse, and the client's physical status.
●● When planning care for a child who has increased intracranial
pressure (ICP), which of the following should the nurse include in the
child's plan of care?
Answer: Maintain head in midline. -The child's head should be
maintained in a midline position to promote venous return and prevent
an increase in ICP.
●●
Answer: Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty
arousing the client from sleep is an indication of increased ICP.//
,Widening pulse pressure is correct. A widening pulse pressure (increase
in systolic with concurrent decrease in diastolic blood pressure) is an
indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate
posturing indicate increased ICP.
●● A nurse is talking with a client who is beginning chemotherapy. She
tells the nurse that she is mourning the loss of her hair. Which of the
following actions should the nurse take first?
Answer: Discuss the importance of hair with the client.--The first action
the nurse should take using the nursing process is to assess the client. By
identifying the importance of hair to the client, the nurse can
acknowledge the importance of the expected loss to the client and assist
the client with anticipatory grieving.
●●
Answer: an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require
planning and math skills, such as managing finances.
●●
Answer: Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic
cerebral palsy.
, ●●
Answer: Discontinue the infusion.--A report of pain and a red line
extending outward from the insertion site are manifestations of phlebitis
and indicates that the client is at the greatest risk from injury to the vein;
therefore, the first action the nurse should take is to discontinue the
infusion.
●● A client who is being discharged today asks the nurse for supplies for
her wound dressing. Which of the following actions should the nurse
take to ensure quality, cost-effective care?
Answer: Provide enough supplies for 1 to 2 days.-Although wound care
supplies for home use are typically purchased by clients after leaving the
facility, it may be necessary to provide adequate supplies for the
immediate discharge period.
●● A nurse is administering baclofen for a client who has a spinal cord
injury. Which of the following should the nurse document as a
therapeutic outcome?
Answer: Decrease in flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms,
allowing for improved muscle function.
●● A nurse is providing postoperative instructions about complete
proteins to a client following a below-the-knee amputation. Which of the
following food choices indicates a need for additional instruction?
Answer: Pinto beans-
